Advance DirectivesInformation PacketAdvance DirectivesInformation Packet

720 North Lincoln StreetGreensburg, Indiana 47240

812-663-4331

www.dcmh.net

The Quality Care You Want. Close By.

Decatur County Memorial Hospital

Healthcare Representative

Living Will Declaration

Life-Prolonging Procedures Declaration

Out of Hospital “Do Not Resuscitate”

Organ and Tissue Donation

Financial Power of Attorney

Physician Order For Scope of Treatment (POST)

Revised: May 1999Revised: July 1, 2013

THE IMPORTANCE OF ADVANCE DIRECTIVES

Each time you visit your physician, you make decisions regarding your personal health care. You tell your doctor (generally referred to as a “physician”) about your medical problems. Your physician makes a diagnosis and informs you about available medical treatment. You then decide what treatment to accept. That process works until you are unable to decide what treatments to accept or become unable to communicate your decisions. Diseases common to aging such as dementia or Alzheimer’s disease may take away your ability to decide and communicate your health care wishes. Even young people can have strokes or accidents that may keep them from making their own health care decisions. Advance directives are a way to manage your future health care when you cannot speak for yourself.

WHAT IS AN ADVANCE DIRECTIVE? “Advance directive” is a term that refers to your spoken and written instructions about your future medical care and treatment. By stating your health care choices in an advance directive, you help your family and physician understand your wishes about your medical care. Indiana law pays special attention to advance directives. Advance directives are normally one or more documents that list your health care instructions. An advance directive may name a person of your choice to make health care choices for you when you cannot make the choices for yourself. If you want, you may use an advance directive to prevent certain people from making health care decisions on your behalf. Your advance directives will not take away your right to decide your current health care. As long as you are able to decide and express your own decisions, your advance directives will not be used. This is true even under the most serious medical conditions. Your advance directive will only be used when you are unable to communicate or when your physician decides that you no longer have the mental competence to make your own choices.

ARE ADVANCE DIRECTIVES REQUIRED?

Advance directives are not required. Your physician or hospital cannot require you to make an advance directive if you do not want one. No one may discriminate against you if you do not sign one. Physicians and hospitals often encourage patients to complete advance directive documents. The purpose of the advance directive is for your physician to gain information about your health care choices so that your wishes can be followed. While completing an advance directive provides guidance to your physician in the event that you are unable to communicate for yourself, you are not required to have an advance directive.

WHAT HAPPENS IF YOU DO NOT HAVE AN ADVANCE DIRECTIVE? If you do not have an advance directive and are unable to choose medical care or treatment, Indiana law decides who can do this for you. Indiana Code § 16-36 allows any member of your immediate family (meaning your spouse, parent, adult child, brother, or sister) or a person appointed by a court to make the choice for you. If you cannot communicate and do not have an advance directive, your physician will try to contact a member of your immediate family. Your health care choices will be made by the family member that your physician is able to contact.

WHAT TYPES OF ADVANCE DIRECTIVES ARE RECOGNIZED IN INDIANA?

• Talking directly to your physician and family • Organ and tissue donation • Health care representative • Living Will Declaration or Life-Prolonging Procedures Declaration • Psychiatric advance directives • Out of Hospital Do Not Resuscitate Declaration and Order • Physician Order for Scope of Treatment (POST)• Power of Attorney

TALKING TO YOUR PHYSICIAN AND FAMILY

One of the most important things to do is to talk about your health care wishes with your physician. Your physician can follow your wishes only if he or she knows what your wishes are. You do not have to write down your health care wishes in an advance directive. By discussing your wishes with your physician, your physician will record your choices in your medical chart so that there is a record available for future reference. Your physician will follow your verbal instructions even if you do not complete a written advance directive. Solely discussing your wishes with your physician, however, does not cover all situations. Your physician may not be available when choices need to be made. Other health care providers would not have a copy of the medical records maintained by your physician and therefore would not know about any verbal instructions given by you to your physician. In addition, spoken instructions provide no written evidence and carry less weight than written instructions if there is a disagreement over your care. Writing down your health care choices in an advance directive document makes your wishes clear and may be necessary to fulfill legal requirements. If you have written advance directives, it is important that you give a copy to your physician. He or she will keep it in your medical chart.

If you are admitted to a hospital, your physician will write orders in your medical chart based on your written advance directives or your spoken instructions. For instance, if you have a fatal disease and do not want cardiopulmonary resuscitation (CPR), your physician will need to write a “do not resuscitate” (DNR) order in your chart. The order makes the hospital staff aware of your wishes. Because most people have several health care providers, you should discuss your wishes with all of your providers and give each provider a copy of your advance directives.

It is difficult to talk with family about dying or being unable to communicate. However, it is important to talk with your family about your wishes and ask them to follow your wishes. You do not always know when or where an illness or accident will occur. It is likely that your family would be the first ones called in an emergency. They are the best source of providing advance directives to a health care provider.

ORGAN AND TISSUE DONATION Increasing the quality of life for another person is the ultimate gift. Donating your organs is a way to help others. Making your wishes concerning organ donation clear to your physician and family is an important first step. This lets them know that you wish to be an organ donor. Organ donation is controlled by the Indiana Revised Uniform Anatomical Gift Act found at Indiana Code § 29-2-16.1. A person that wants to donate organs may include their choice in their will, living will, on a card, or other document. If you do not have a written document for organ donation, someone else will make the choice for you. A common method used to show that you are an organ donor is making the choice on your driver’s license. When you get a new or renewed license, you can ask the license branch to mark your license showing you are an organ donor.

HEALTH CARE REPRESENTATIVE

A “health care representative” is a person you choose to receive health care information and make health care decisions for you when you cannot. To choose a health care representative, you must fill out an appointment of health care representative document that names the person you choose to act for you or you must complete the appointment of health care representative section found on a POST form. Your health care representative may agree to or refuse medical care and treatments when you are unable to do so. Your representative will make these choices based on your advance directive. If you want, in certain cases and in consultation with your physician, your health care representative may decide if food, water, or respiration should be given artificially as part of your medical treatment.

Choosing a health care representative is part of the Indiana Health Care Consent Act, found at Indiana Code § 16-36-1. Appointing a health care representative is also authorized via designation in a POST form at Indiana Code § 16-36-6. Under both instances, the advance directive or POST form naming a health care representative must be in writing, signed by you, and witnessed by another adult. Because these are serious decisions, your health care representative must make them in your best interest. Indiana courts have made it clear that decisions made for you by your health care representative should be honored.

LIVING WILL

A “living will” is a written document that puts into words your wishes in the event that you become terminally ill and unable to communicate. A living will is an advance directive that lists the specific care or treatment you want or do not want during a terminal illness. A living will often includes directions for CPR, artificial nutrition, maintenance on a respirator, and blood transfusions. The Indiana Living Will Act is found at Indiana Code § 16-36-4. This law allows you to write one of two kinds of advance directive.

Living Will Declaration: This document is used to tell your physician and family that life-prolonging treatments should not be used so that you are allowed to die naturally. Your living will does not have to prohibit all life-prolonging treatments. Your living will should list your specific choices. For example, your living will may state that you do not want to be placed on a respirator but that you want a feeding tube for nutrition. You may even specify that someone else should make the decision for you.

Life-Prolonging Procedures Declaration: This document is the opposite of a living will. You can use this document if you want all life-prolonging medical treatments used to extend your life.

Both of these documents can be canceled orally, in writing, or by destroying the declaration yourself. The cancellation takes effect only when you tell your physician. For either of these documents to be used, there must be two adult witnesses and the document must be in writing and signed by you or someone that has permission to sign your name in your presence.

PSYCHIATRIC ADVANCE DIRECTIVE

Any person may make a psychiatric advance directive if he/she has legal capacity. This written document expresses your preferences and consent to treatment measures for a specific diagnosis. The directive sets forth the care and treatment of a mental illness during periods of incapacity. This directive requires certain items in order for the directive to be valid. Indiana Code § 16-36-1.7 provides the requirements for this type of advance directive.

OUT OF HOSPITAL DO NOT RESUSCITATE DECLARATION AND ORDER

In a hospital, if you have a terminal condition and you do not want CPR, your physician will write a “do not resuscitate” order in your medical chart. If you are not in a hospital when an emergency occurs, the emergency medical personnel or the hospital where you are sent likely would not have a physician’s order to implement your directives. For situations outside of a hospital, the Out of Hospital Do Not Resuscitate Declaration and Order is used to state your wishes. The Out of Hospital Do Not Resuscitate Declaration and Order is found at Indiana Code § 16-36-5.

The law allows a qualified person to say they do not want CPR given if the heart or lungs stop working in a location that is not a hospital. This declaration may override other advance directives. The declaration may be canceled by you at any time by a signed and dated writing, by destroying or canceling the document, or by communicating to health care providers at the scene your desire to cancel the order. Emergency Medical Services (EMS) may have procedures in place for marking your home so they know you have an order. You should contact your local EMS provider to find out their procedures.

POWER OF ATTORNEY

A “power of attorney” (also referred to as a “durable power of attorney”) is another kind of advance directive. This document is used to grant another person say-so over your affairs. Your power of attorney document may cover financial matters, give health care authority, or both. By giving this power to another person, you give this person your power of attorney. The legal term for the person you choose is “attorney in fact.” Your attorney in fact does not have to be an attorney. Your attorney in fact can be any adult you trust. Your attorney in fact is given the power to act for you only in the ways that you list in the document. The document must: 1. Name the person you want as your attorney in fact; 2. List the situations which give the attorney in fact the power to act; 3. List the powers you want to give; and 4. List the powers you do not want to give.

The person you name as your power of attorney is not required to accept the responsibility. Prior to executing a power of attorney document, you should talk with the person to ensure that he or she is willing to serve. A power of attorney document may be used to designate a health care representative. Health care powers are granted in the power of attorney document by naming your attorney in fact as your health care representative under the Health Care Consent Act or by referring to the Living Will Act. When a power of attorney document is used to name a health care representative, this person is referred to as your health care power of attorney. A health care power of attorney generally serves the same role as a health care representative in a health care representative advance directive. Including health care powers could allow your attorney in fact to: 1. Make choices about your health care; 2. Sign health care contracts for you; 3. Admit or release you from hospitals or other health facilities; 4. Look at or get copies of your medical records; and 5. Do a number of other things in your name.

The Indiana Powers of Attorney Act is found at Indiana Code § 30-5. Your power of attorney document must be in writing and signed in the presence of a notary public. You can cancel a power of attorney at any time but only by signing a written cancellation and having the cancellation delivered to your attorney in fact.

PHYSICIAN ORDERS FOR SCOPE OF TREATMENT (POST)

A “Physician Orders for Scope of Treatment” (also referred to as a POST form) is a direct physician order for a person with at least one of the following:

1. An advanced chronic progressive illness.2. An advanced chronic progressive frailty.3. A condition caused by injury, disease, or illness from which, to a reasonable degree of medical

certainty there can be no recovery and death will occur from the condition within a short period without the provision of life prolonging procedures.

4. A medical condition that, if the person were to suffer cardiac or pulmonary failure, resuscitation would be unsuccessful or within a short period the person would experience repeated cardiac or pulmonary failure resulting in death.

In consultation with you or your legal representative, your physician will write orders that reflect your wishes with regards to cardiopulmonary resuscitation (CPR), medical interventions (comfort measures, limited additional interventions, or full treatment), antibiotics and artificially administered nutrition. You additionally have the option on the POST form to designate a “Health Care Representative” [see the section “Health Care Representative” above for additional information]. Note that if you have previously designated a health care representative and you name a different person on your POST form, the person designated on the POST form replaces (revokes) the person named in the previous health care representative advance directive. The Indiana POST form is available on the Indiana State Department of Health website at www.in.gov/isdh/25880.htm.

The POST form must be signed and dated by you (or your legal representative) and your physician to be valid. The original form is your personal property and you should keep it. Paper, facsimile (fax), or electronic copies of a valid POST form are as valid as the original. Your physician is required to keep a copy of your POST form in your medical record or; if the POST form is executed in a health facility, the facility must maintain a copy of the form in the medical record. The POST form may be used in any health care setting. The Physician Orders for Scope of Treatment statute is found at Indiana Code § 16-36-6.

Executed POST forms may be revoked at any time by any of the following:1. A signed and dated writing by you or your legal representative.2. Physical cancellation of destruction of the POST form by you or your legal representative.3. Another individual at the direction of you or your legal representative.4. An oral expression by you or your legal representative of intent to revoke the POST form.

The revocation is effective upon communication of the revocation to a health care provider.

WHICH ADVANCE DIRECTIVE OR DIRECTIVES SHOULD BE USED?

The choice of advance directives depends on what you are trying to do. The advance directives may be used alone or together. The laws are complex and it is always wise to talk to an attorney about questions and your legal choices. An attorney is often helpful in advising you on complex family matters and making sure that your documents are correctly done under Indiana law. An attorney may be helpful if you live in more than one state during the year. An attorney can advise you whether advance directives completed in another state are recognized in Indiana.

CAN I CHANGE MY MIND AFTER I WRITE AN ADVANCE DIRECTIVE?

It is important to discuss your advance directives with your family and health care providers. Your health care wishes cannot be followed unless someone knows your wishes. You may change or cancel your advance directives at any time as long as you are of sound mind. If you change your mind, you need to tell your family, health care representative, power of attorney, and health care providers. You might have to cancel your decision in writing for it to become effective. Always be sure to talk directly with your physician and tell him or her your exact wishes.

FINAL THOUGHTS ABOUT ADVANCE DIRECTIVES • You have the right to choose the medical care and treatment you receive. Advance

directives help make sure you have a say in your future health care and treatment if you become unable to communicate.

• Even if you do not have written advance directives, it is important to make sure your physician and family are aware of your health care wishes.

• No one can discriminate against you for signing, or not signing, an advance directive. An advance directive is, however, your way to control your future medical treatment.

• This information was prepared by the Indiana State Department of Health as an overview of advance directives. The Indiana State Department of Health attorneys cannot give you legal advice concerning living wills or advance directives. You should talk with your personal lawyer or representative for advice and assistance in this matter.

Indiana State Department of Health 2 North Meridian Street

Indianapolis, Indiana 46204 http://www.in.gov/isdh

ARE THERE FORMS TO HELP IN WRITING THESE DOCUMENTS?

Advance directive forms are available from many sources. Most physicians, hospitals, health facilities, or senior citizen groups can provide you with forms or refer you to a source. These groups often have the information on their web sites. You should be aware that forms may not do everything you want done. Forms may need to be changed to meet your needs. Although advance directives do not require an attorney, you may wish to consult with one before you try to write one of the more complex legal documents listed above.

Several of the forms are specified by statute. Those forms may be found on the Indiana State Department of Health (ISDH) Advance Directives Resource Center at www.in.gov/isdh/25880.htm. The following forms are available on that web site: • Living Will Declaration • Life-Prolonging Procedures Declaration • Out of Hospital Do Not Resuscitate Declaration and Order • Physician Orders for Scope of Treatment (POST)

WHAT SHOULD I DO WITH MY ADVANCE DIRECTIVE IF I CHOOSE TO HAVE ONE?

Make sure that your health care representative, immediate family members, physician, attorney, and other health care providers know that you have an advance directive. Be sure to tell them where it is located. You should ask your physician and other health care providers to make your advance directives part of your permanent medical chart. If you have a power of attorney, you should give a copy of your advance directives to your attorney in fact. You may wish to keep a small card in your purse or wallet that states that you have an advance directive, where it is located, and who to contact for your attorney in fact or health care representative, if you have named one.

ADDITIONAL INFORMATION

For additional information on advance directives, visit the Indiana State Department of Health Advanced Directives Resource Center located at www.in.gov/isdh/25880.htm. The site includes links to state forms, this brochure, links to Indiana statutes, and links to other web sites.

The ISDH Web site contains a wealth of information about public health. Visit the ISDH Home Page at www.in.gov/isdh.

DECATUR COUNTY MEMORIAL HOSPITAL RESPECTS YOUR RIGHT TO DECIDE

Protecting your right to express choice through Advance Directives upholds the DCMH value of respect which “supports the rights of the patient to participate in all decisions that affect their health care.” Federal law (the Patient Self-Determination Act of 1990), and the Center for Medicare and Medicaid Services require that every health care institution ask patients if they have an Advance Directive and provide Advance Directive information to patients who request it.

The following information is provided to you by Decatur County Memorial Hospital as a brief overview regarding Advance Directives in Indiana to help you gain a better understanding of your right to decide about your treatment. Advance Directives allow you, while you are of sound mind, to state your healthcare preferences if you cannot speak for yourself or lose your decision making capacity and/or to appoint someone to make your healthcare decisions for you.

What if I make an advance directive in Indiana and I am hospitalized in a different state, or vice versa? The law on honoring an advance directive in or from another state is unclear. If you spend a great deal of time in more than one state, you may wish to consider having your advance directive meet the laws of those states.

WITNESSES cannot be your parent(s), spouse, child/children, or persons who can benefit from your estate or who are financially responsible for you. Witnesses must be competent and at least eighteen years of age. Make sure your witness or notary is present when you sign your document.

IF YOU NEED ASSISTANCE: Although an attorney is not required, you may want to talk with one. In addition, a social worker at Decatur County Memorial Hospital is available to answer questions and can be reached at (812) 663-1176. However, a social worker cannot give you legal advice concerning Advanced Directives.

We cannot stress enough that communication is extremely important. Discuss all documents and your ideas about quality of life with your Healthcare Representative, physician(s), family members, friends and clergy, and provide them with a signed copy of your Advanced Directives. You may revoke or change these documents. Periodically review your documents. If there are no changes after each review, initial and date in the margin. Feel free, at any time, to bring your Advance Directive documents to Decatur County Memorial Hospital Health Information Department, where it will be filed in your medical record.

Please retain all originals for your records. Remember, the documents must be on your medical record to be honored.

1. The Indiana Living Will Declaration allows you to refuse life-prolonging procedures that could prolong the dying process. It does not prevent you from receiving comfort care such as pain medication and oxygen.

2. The Indiana Life-Prolonging Procedures Declaration allows you to request the use of all life-prolonging procedures even when the physician deems there is no hope for survival.

3. The Out of Hospital Do Not Resuscitate Declaration and Order allows you to request resuscitation procedures be stopped or never started and allows you to die with comfort care. This form is also effective when you are not in a hospital. This form must be filled out and signed by a physician.

4. The Appointment of Health Care Representative allows you to name someone to make decisions about your medical care – including decisions about life support if you are unable to make your own medical decisions and have not appointed a specific person to speak on your behalf. Indiana law says health care decisions can be made by a spouse, a parent, an adult child or an adult sibling.

5. The Physician Scope of Treatment (POST) form creates orders for end of life patients that remains in effect across all care settings including nursing homes, home or community settings, including hospitals and an ambulance. This form must be signed by a physician. This form covers many areas related to your health care.

6. The Durable Financial Power of Attorney form allows you to appoint someone to have authority over your finances. This document must be notarized and becomes effective immediately. Your power of attorney should be someone you trust. If your intent is to allow your financial power of attorney to make property transactions on your behalf, then your completed document must be filed with the county recorder’s office. The documents provided in this booklet are regarding financial matters only; it is not a healthcare power of attorney.

7. The Organ/Tissue/Total Body Donation form discusses your wishes with your family/representative. Give them the opportunity to allow your wishes to come true. Total body donation requires application/approval prior to your death.

8. The Psychiatric Advance Directive allows you, in consultation with your psychiatrist, to express mental health treatment preferences. This form is available only through your psychiatrist or other mental health counselor.

ORGAN, TISSUE AND TOTAL BODY DONATION

If your wishes are to become an organ, tissue or total body donor at the time of your death, discuss your wishes with your family or healthcare representative.

Indiana Donor Network (Tissue and Organ) or the Anatomical Education Program (Total Body Donor) will make the decision at the time of your death whether or not organ, tissue or full body donation is an option. Total Body Donation requires prior arrangements. All cost related to the donation are covered by the organ, tissue and body recovering agencies. There is no change to the donor’s appearance or to customary funeral arrangements for organ and tissue donations.

1. If you have questions about tissue and organ donation or would like to register as a donor:

Visit: www.indianadonornetwork.org and complete a donor registration form Call: 1-888-275-4676 BMV: Register when you renew your license

2. If you would like to donate your body to science, have questions about donating your body or would like to register as a donor:

Visit: anatomy.medicine.iu.edu (go to Body Donation) and complete Certificate of Bequeathal form Call: 317-274-7450 Anatomical Education Program of the Indiana University School of Medicine

The following forms are specified by the Indiana statute. They are also

available on the Indiana State Department of Health website:

www.in.gov/isdh/25880.htm

INDIANA LIVING WILL DECLARATIONState Form 55316 (6-13)Indiana State Department of Health – IC 16-36-4

This declaration is effective on the date of execution and remains in effect until revocation or the death of the declarant. This declaration should be provided to your physician.

LIVING WILL DECLARATION

Declaration made this day of (month, year). I, ,being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I declare:

If at any time my attending physician certifies in writing that: (1) I have an incurable injury, disease, or illness; (2) my death will occur within a short time; and (3) the use of life prolonging procedures would serve only to artificially prolong the dying process,

I direct that such procedures be withheld or withdrawn and that I be permitted to die naturally with only the performance or provision of any medical procedure or medication necessary to provide me with comfort care or to alleviate pain, and, if I have so indicated below, the provision of artificially supplied nutrition and hydration. (Indicate your choice by initialing or making your mark before signing this declaration.):

__________ I wish to receive artificially supplied nutrition and hydration, even if the effort to sustain life is futile or excessively burdensome to me.

__________ I do not wish to receive artificially supplied nutrition and hydration, if the effort to sustain life is futile or excessively burdensome to me.

__________ I intentionally make no decision concerning artificially supplied nutrition and hydration, leaving the decision to my health care representative appointed under IC 16-36-1-7 or my attorney in fact with health care powers under IC 30-5-5.

In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of the refusal.

I understand the full import of this declaration.

Signature

City, County, and State of Residence

WITNESSES

The declarant has been personally known to me and I believe (him/her) to be of sound mind. I did not sign the declarant's signature above for or at the direction of the declarant. I am not a parent, spouse, or child of the declarant. I am not entitled to any part of the declarant's estate or directly financially responsible for the declarant's medical care. I am competent and at least eighteen (18) years of age.

Witness __________________________________ Date (month, day, year) _____________________

Witness __________________________________ Date (month, day, year) _____________________

Printed Name

Date of Birth

INDIANA LIFE PROLONGING PROCEDURES DECLARATIONState Form 55315 (6-13)Indiana State Department of Health – IC 16-36-4

This declaration is effective on the date of execution and remains in effect until revocation or the death of the declarant. This declaration should be provided to your physician.

LIFE PROLONGING PROCEDURES DECLARATION

Declaration made this day of (month, year). I, ,being at least eighteen (18) years of age and of sound mind, willfully and voluntarily make known my desire that if at any time I have an incurable injury, disease, or illness determined to be a terminal condition I request the use of life prolonging procedures that would extend my life. This includes appropriate nutrition and hydration, the administration of medication, and the performance of all other medical procedures necessary to extend my life, to provide comfort care, or to alleviate pain.

In the absence of my ability to give directions regarding the use of life prolonging procedures, it is my intention that this declaration be honored by my family and physician as the final expression of my legal right to request medical or surgical treatment and accept the consequences of the request.

I understand the full import of this declaration.

City, County, and State of Residence

WITNESSES

The declarant has been personally known to me and I believe (him/her) to be of sound mind. I am competent and at least eighteen (18) years of age.

Witness __________________________________ Date (month, day, year) _____________________

Witness __________________________________ Date (month, day, year) _____________________

SignaturePrinted Name

Date of Birth

Date of Birth

INDIANA DURABLE POWER OF ATTORNEY

NOTICE: IC 30.5 IF YOU HAVE ANY QUESTIONS ABOUT THESE POWERS, OBTAIN COMPETENT LEGAL ADVICE. THIS DOCUMENT IS A FINANCIAL POWER OF ATTORNEY. IT DOES NOT AUTHORIZE ANYONE TO MAKE HEALTH-CARE DECISIONS FOR YOU. YOU MAY REVOKE THIS POWER OF ATTORNEY AT ANYTIME. THIS POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE TO BE EFFECTIVE EVEN IF YOU BECOME DISABLED, INCAPACITATED, OR INCOMPETENT.

Insert the name(s) and address(es)of the person appointed as my Agent (attorney-in-fact) to act for me in any lawful way with respect to the following initialed subjects:

Each agent may act independent of the other: Yes No

TO GRANT THE FOLLOWING POWERS, INITIAL THE LINE IN FRONT OF EACH POWER YOU ARE GRANTING.

INITIAL EACH POWER YOU ARE GRANTING:

_______ (A) REAL PROPERTY TRANSACTIONS. To lease, sell, mortgage, purchase, exchange, acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and acquisition of, and to accept, take, receive, and possess any interest in real property whatsoever, on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to maintain, repair, tear down, alter, rebuild, improve manage, insure, move, rent, lease, sell, convey, subject to liens, mortgages, and security deeds, and in any way or manner deal with all or any part of any interest in real property whatsoever, including specifically, but without limitation, real property lying and being situated in the State of Indiana, under such terms and conditions, and under such covenants, as my Agent shall deem proper and may for all deferred payments accept purchase money notes payable to me and secured by mortgages or deeds to secure debt, and may from time to time collect and cancel any of said notes, mortgages, security interests, or deeds to secure debt. _______ (B) TANGIBLE PERSONAL PROPERTY TRANSACTIONS. To lease, sell, mortgage, purchase, exchange, acquire, and to agree, bargain, and contract for the lease, sale, purchase, exchange, and acquisition of, and to accept, take, receive, and possess any personal property whatsoever, tangible or intangible, or interest thereto, on such terms and conditions, and under such covenants, as my Agent shall deem proper; and to maintain, repair, improve, manage, insure, rent, lease, sell, convey, subject to liens or mortgages, or to take any other security interests in said property which are recognized under the Uniform Commercial Code as adopted at that time under the laws of the State of Indiana or any applicable state, or otherwise hypothecate (pledge), and in any way or manner deal with all or any part of any real or personal property whatsoever, tangible or intangible, or any interest therein, that I own at the time of execution or may thereafter acquire, under such terms and conditions, and under such covenants, as my Agent shall deem proper.

( )

Printed Name of Appointed Financial Power of Attorney (Agent)

Address

Telephone Number

Printed Name of Appointed Financial Power of Attorney (Agent)

Address

Telephone Number

_______ (C) Stock and bond transactions. To purchase, sell, exchange, surrender, assign, redeem, vote at any meeting, or otherwise transfer any and all shares of stock, bonds, or other securities in any business, association, corporation, partnership, or other legal entity, whether private or public, now or hereafter belonging to me.

_______ (D) Commodity and option transactions. To organize or continue and conduct any business which term includes, without limitation, any farming, manufacturing, service, mining, retailing or other type of business operation in any form, whether as a proprietorship, joint venture, partnership, corporation, trust or other legal entity; operate, buy, sell, expand, contract, terminate or liquidate any business; direct, control, supervise, manage or participate in the operation of any business and engage, compensate and discharge business managers, employees, agents, attorneys, accountants and consultants; and, in general, exercise all powers with respect to business interests and operations which the principal could if present and under no disability.

_______ (E) Banking and other financial institution transactions. To make, receive, sign, endorse, execute, acknowledge, deliver and possess checks, drafts, bills of exchange, letters of credit, notes, stock certificates, withdrawal receipts and deposit instruments relating to accounts or deposits in, or certificates of deposit of banks, savings and loans, credit unions, or other institutions or associations. To pay all sums of money, at any time or times, that may hereafter be owing by me upon any account, bill of exchange, check, draft, purchase, contract, note, or trade acceptance made, executed, endorsed, accepted, and delivered by me or for me in my name, by my Agent. To borrow from time to time such sums of money as my Agent may deem proper and execute promissory notes, security deeds or agreements, financing statements, or other security instruments in such form as the lender may request and renew said notes and security instruments from time to time in whole or in part. To have free access at any time or times to any safe deposit box or vault to which I might have access.

_______ (F) Business operating transactions. To conduct, engage in, and otherwise transact the affairs of any and all lawful business ventures of whatever nature or kind that I may now or hereafter be involved in.

_______ (G) Insurance and annuity transactions. To exercise or perform any act, power, duty, right, or obligation, in regard to any contract of life, accident, health, disability, liability, or other type of insurance or any combination of insurance; and to procure new or additional contracts of insurance for me and to designate the beneficiary of same; provided, however, that my Agent cannot designate himself or herself as beneficiary of any such insurance contracts.

_______ (H) Estate, trust, and other beneficiary transactions. To accept, receipt for, exercise, release, reject, renounce, assign, disclaim, demand, sue for, claim and recover any legacy, bequest, devise, gift or other property interest or payment due or payable to or for the principal; assert any interest in and exercise any power over any trust, estate or property subject to fiduciary control; establish a revocable trust solely for the benefit of the principal that terminates at the death of the principal and is then distributable to the legal representative of the estate of the principal; and, in general, exercise all powers with respect to estates and trusts which the principal could exercise if present and under no disability; provided, however, that the Agent may not make or change a will and may not revoke or amend a trust revocable or amendable by the principal or require the trustee of any trust for the benefit of the principal to pay income or principal to the Agent unless specific authority to that end is given.

_______ (I) Claims and litigation. To commence, prosecute, discontinue, or defend all actions or other legal proceedings touching my property, real or personal, or any part thereof, or touching any matter in which I or my property, real or personal, may be in any way concerned. To defend, settle, adjust, make allowances, compound, submit to arbitration, and compromise all accounts, reckonings, claims, and demands whatsoever that now are, or hereafter shall be, pending between me and any person, firm, corporation, or other legal entity, in such manner and in all respects as my Agent shall deem proper.

_______ (J) Personal and family maintenance. To hire accountants, attorneys at law, consultants, clerks, physicians, nurses, agents, servants, workmen, and others and to remove them, and to appoint others in their place, and to pay and allow the persons so employed such salaries, wages, or other remunerations, as my Agent shall deem proper.

_______ (K) Benefits from Social Security, Medicare, Medicaid, or other governmental programs, or military service. To prepare, sign and file any claim or application for Social Security, unemployment or military service benefits; sue for, settle or abandon any claims to any benefit or assistance under any federal, state, local or foreign statute or regulation; control, deposit to any account, collect, receipt for, and take title to and hold all benefits under

any Social Security, unemployment, military service or other state, federal, local or foreign statute or regulation; and, in general, exercise all powers with respect to Social Security, unemployment, military service, and governmental benefits, including but not limited to Medicare and Medicaid, which the principal could exercise if present and under no disability.

______ (L) Retirement plan transactions. To contribute to, withdraw from and deposit funds in any type of retirement plan (which term includes, without limitation, any tax qualified or nonqualified pension, profit sharing, stock bonus, employee savings and other retirement plan, individual retirement account, deferred compensation plan and any other type of employee benefit plan); select and change payment options for the principal under any retirement plan; make rollover contributions from any retirement plan to other retirement plans or individual retirement accounts; exercise all investment powers available under any type of self-directed retirement plan; and, in general, exercise all powers with respect to retirement plans and retirement plan account balances which the principal could if present and under no disability.

_______ (M) Tax matters. To prepare, to make elections, to execute and to file all tax, social security, unemployment insurance, and informational returns required by the laws of the United States, or of any state or subdivision thereof, or of any foreign government; to prepare, to execute, and to file all other papers and instruments which the Agent shall think to be desirable or necessary for safeguarding of me against excess or illegal taxation or against penalties imposed for claimed violation of any law or other governmental regulation; and to pay, to compromise, or to contest or to apply for refunds in connection with any taxes or assessments for which I am or may be liable.

SPECIAL INSTRUCTIONS:

ON THE FOLLOWING LINES YOU MAY GIVE SPECIAL INSTRUCTIONS LIMITING OR EXTENDING THE POWERS GRANTED TO YOUR AGENT.

_____________________________________________________________________________________________ _____________________________________________________________________________________________

(YOUR AGENT WILL HAVE AUTHORITY TO EMPLOY OTHER PERSONS AS NECESSARY TO ENABLE THE AGENT TO PROPERLY EXERCISE THE POWERS GRANTED IN THIS FORM, BUT YOUR AGENT WILL HAVE TO MAKE ALL DISCRETIONARY DECISIONS. IF YOU WANT TO GIVE YOUR AGENT THE RIGHT TO DELEGATE DISCRETIONARY DECISION-MAKING POWERS TO OTHERS, YOU SHOULD KEEP THE NEXT SENTENCE, OTHERWISE IT SHOULD BE STRICKEN.)

Authority to Delegate. My Agent shall have the right by written instrument to delegate any or all of the foregoing powers involving discretionary decision-making to any person or persons whom my Agent may select, but such delegation may be amended or revoked by any agent (including any successor) named by me who is acting under this power of attorney at the time of reference.

(IF YOU WISH TO NAME SUCCESSOR AGENTS, INSERT THE NAME(S), ADDRESS(ES) AND TELEPHONE NUMBER(S) OF SUCH SUCCESSOR(S) IN THE FOLLOWING PARAGRAPH.) Successor Agent. If any Agent named by me shall die, become incompetent, resign or refuse to accept the office of Agent, I name the following (each to act alone and successively, in the order named) as successor(s) to such Agent:

Optional: Signature of Successor Agent(s)

(YOUR AGENT IS ENTITLED TO REIMBURSEMENT FOR ALL REASONABLE EXPENSES INCURRED WHILE ACTING UNDER THIS POWER OF ATTORNEY.

(STRIKE OUT THE NEXT SENTENCE IF YOU DO NOT WANT YOUR AGENT TO ALSO BE ENTITLED TO REASONABLE COMPENSATION FOR SERVICES AS YOUR AGENT.) Right to Compensation. My Agent shall be entitled to reasonable compensation for services rendered as agent under this power of attorney.

Name DOB Phone Name DOB Phone

Choice of Law. THIS POWER OF ATTORNEY WILL BE GOVERNED BY THE LAWS OF THE STATE OF INDIANA WITHOUT REGARD FOR CONFLICTS OF LAWS PRINCIPLES. IT WAS EXECUTED IN THE STATE OF INDIANA AND IS INTENDED TO BE VALID IN ALL JURISDICTIONS OF THE UNITED STATES OF AMERICA AND ALL FOREIGN NATIONS.

LIABILITY AND INDEMNITY: My attorney-in-fact shall only be liable for actions undertaken in bad faith; provided, however, my attorney-in-fact shall be liable for the negligent exercise of the powers described herein if the exercise of such power involves self-dealing. I hereby ratify and confirm all that my attorney-in-fact shall do by virtue hereof. Further, I agree to indemnify and hold harmless any person who, in good faith,acts under this Power of Attorney or transacts business with my attorney-in-fact in reliance upon this Power, without actual knowledge of it revocation.

THIS FINANCIAL POWER OF ATTORNEY IS EFFECTIVE IMMEDIATELY AND WILL CONTINUE UNTIL IT IS REVOKED. THIS POWER OF ATTORNEY SHALL BE CONSTRUED AS A GENERAL DURABLE POWER OF ATTORNEY AND SHALL CONTINUE TO BE EFFECTIVE EVEN IF I BECOME DISABLED, INCAPACITATED, OR INCOMPETENT.

APPOINTMENT OF GUARDIAN OR CONSERVATOR

I designate ____________________________________________________________________________________[agent(s) name(s)], as my guardian(s) or conservator(s) should a guardianship or conservatorship be established for my person or property.

I am fully informed as to all the contents of this form and understand the full import of this grant of powers to my Agent.

I agree that any third party who receives a copy of this document may act under it. Revocation of the power of attorney is not effective as to a third party until the third party learns of the revocation. I agree to indemnify the third party for any claims that arise against the third party because of reliance on this pwer of attorney.

Signed this _______ day of ______________________, 20_____ DOB ________________________________

_________________________________________________ _____________________________________Printed Name of Principal Signature of Principal

ACKNOWLEDGMENT OF AGENT Acceptance Signature (optional)BY ACCEPTING OR ACTING UNDER THE APPOINTMENT, THE AGENT ASSUMES THE FIDUCIARY AND OTHER LEGAL RESPONSIBILITIES OF AN AGENT.

______________________________________________ ___________________________________________Agent Signature [Financial Power of Attorney / Date] Agent Signature [Financial Power of Attorney / Date]

CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC

STATE OF INDIANA: COUNTY OF ________________

This document was acknowledged before me on _______________________ [Date] by

____________________________________________________________ [name of principal].

[Notary Seal, if any]: _______________________________________ (Signature of Notarial Officer) Notary Public for the State of Indiana My commission expires: ___________________

Indiana Physician Orders for Scope of Treatment (POST) Information for Patients about POST November 2016

The Indiana Physician Orders for Scope of Treatment (POST) form is a physician’s order determined by the patient’s goals and the treatment options available to a patient based on the individual’s current health. The POST is intended to record a patient’s wishes for medical treatment. The following is intended to provide you with general information about the POST form: The POST form:

The POST form is always voluntary. A health care provider or facility cannot require you to complete a POST form.

The original POST form is the personal property of the patient. You are encouraged to keep the original POST form; however, photocopies, electronic copies, and faxes are also legal and valid. Your treating physician should retain a copy in your medical record.

The State periodically updates the POST form. Previous completed versions of the form are still valid. HIPAA permits disclosure of the POST to health care professionals as necessary for treatment. The POST form may be printed on white paper. There is no requirement that a POST form be printed on a

particular color of paper. Completing the POST:

A family member of an adult patient is not authorized to complete and sign a POST unless the family member has been appointed in writing as the legal representative for the patient.

Provisions of the Physician Orders for Scope of Treatment (POST):

The POST should reflect your current treatment preferences. Any section of the form not completed implies authorization for full treatment for provisions described in that

section. The POST is a medical order and requires the signature of the treating physician to be legally valid.

Changing Physician Orders for Scope of Treatment (POST):

Once initial medical treatment is begun and the risks and benefits of further treatment are clear, your treatment wishes may change. You may change the POST at any time to reflect your current treatment wishes.

Reviewing Physician Orders for Scope of Treatment (POST): Your POST form should be reviewed in the following circumstances:

There is a substantial change in your health status. You are transferred from one care setting or care level to another. Your treating physician changes. Your treatment preferences change.

Revoking Physician Orders for Scope of Treatment (POST):

A person with capacity, or the valid representative of a person without capacity, can revoke the POST at any time by any of the following: a signed and dated writing; physical cancellation or destruction; by another individual at the direction of the declarant or representative; or an oral expression of an intent to revoke. The revocation is effective upon communication to a health care provider.

Advance Directives:

No form can address all the medical treatment decisions that may need to be made. There are numerous types of advance directives. You are encouraged to discuss advance directives with your attorney, physician, or other qualified individual. Your physician can provide you with information about POST and whether it is appropriate for you.

An advance directive, including appointing someone to speak on your behalf if you cannot speak for yourself, is recommended. The ISDH has an Advance Directive Resource Center at www.in.gov/isdh/25880 that provides a brochure, forms, and information about advance directives.

720 North Lincoln StreetGreensburg, Indiana 47240

812.663.4331www.dcmh.net

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Decatur County Memorial Hospital

Revised 1/4/2018